The Arm: Pain Issues, and A Probable Re-Do

My most recent post about breaking my arm and the subsequent recovery process, "Two Steps Back", reported that I'd started experiencing a recurrence of pain at a level similar to a month or so after the surgery in December.

Up to that point, about mid-March, recovery had been slow but forward.  My range of motion and ability to use the right arm fell into three categories:

• The Functional Zone, essentially pain-free, mostly involving use of the hand, wrist and forearm, plus about 40 to 45 degrees of forward-lifting motion (less for sideways motion) for the arm as a whole. 
• Then there was the Uncomfortable Zone, up to about 90 degrees forward, where I could feel some strain and aching while I was using the arm, but the strain and ache would recede quickly when I dropped back into the Functional Zone. 
• Then there was the Forbidden Zone, trying to go up past that 90-degree point (only a few degrees unassisted, a bit further with assistance or exercise pulleys), where the aching slid into the point of actual sharp pain, and where it would still ache and throb for a fair while after dropping back into the more usable Zones. 
• Also, the overall strength of the arm was much better than when I first started therapy for the arm, but still a lot weaker than before the accident.

A lot of that progress has been lost.  When the pain started getting worse again, it was accompanied by intermittent scraping and grating sensations from within the shoulder.  (Not all the time, but any scraping sensations is cause for worry.)  Currently, even when the arm is just hanging at my side, there's a slight but noticeable aching; using the arm beyond that, even the light use I hadn't had much trouble with, makes the aching stronger, eventually going into actual sharp pain.  I've gone back to wearing my arm sling again when it gets bad; having the arm supported gives some relief, but it still takes longer, sometimes a lot longer, for the pain and aching to recede. 

The Functional Zone has shrunk, the Uncomfortable Zone has increased, the Forbidden Zone is still forbidden, and pain has become more chronic again.  This is not good.

I had a fresh set of x-rays done after the grating sensations started, and I was able to move up my next appointment with my orthopedic doctor at Mayo.  I saw him yesterday.

I was hoping what he'd tell me was "Your problem's simple.  I can do a laproscopic procedure, minimally invasive, in and out the same day, and you'll be back on track to recovery quickly."

No such luck.  The major source of problems appears to be that the tuberosity where the rotator cuff attaches to the humerus head replacement is displaced by a significant margin.  This is equivalent to having a major rotator cuff tear.  (And probably explains why I was able to get my arm up to 90 degrees with therapy, but increases beyond that have been minimal and painful.)

My doctor at Mayo isn't the surgeon who replaced the joint in December.  Immediately after the accident, I was taken to the closest hospital with a trauma unit, and the surgery was done there, not at Mayo, where I receive most of my usual medical care.  While it's a nearly unbreakable rule for doctors to badmouth other doctors, I felt a clear vibe of "If it had been me doing the replacement, you wouldn't have this problem."

A couple of additional factors may also be contributing:  Besides the actual break in the arm bone, the shoulder bones were badly compressed and squeezed in the accident.  There may still be lingering trauma after-effects from that.  And there was also a small shadow in the new x-ray that the doctor thought might be a loose bone fragment floating free.

The doctor offered several possible ways to proceed from this point:

• Continue as before, with exercise and physical therapy, and hope that the pain and other problems get better.
• Accept living a life with chronic pain.
• Or go back into surgery for a reverse shoulder arthroplasty, replacing the first artificial joint with a different type.

The reverse shoulder prosthesis works backwards from the standard replacement prosthesis: Instead of putting a new ball-head on the arm bone, the ball head is screwed into the shoulder joint and a "cup" for it to fit into the arm bone.  Also, with the reverse prosthesis, arm and shoulder movement comes primarily from the deltoid muscle, rather than the rotator cuff.

The different joint won't give me a better range of motion.  Best results will still probably fall into the 75% to 85% range.  So even in a best-case scenario, my right arm is going to have limitations for the rest of my life.  OK, I can accept that.  I can live with that. I can do work-arounds for that.  (As if I had a choice.)

The chronic pain issue is a lot more intimidating.  A lot scarier.  Because this: Pain makes you stupid.

When you're in pain, even when you're not actually sweating or whimpering,  even when it's "normal pain" and not "sharp pain" or "intense pain", it's there, in your head, making itself known, insisting you recognize it.  It takes up brainspace that would normally be available for the ubiquitous "stuff" our lives are filled with.  Pain makes you lose focus, lose attention, lose thought.  Pain makes you stupid.

I'm not the most focused or organized person, to say the least.  (I suspect I'd probably score fairly high on an attention-deficit-disorder checklist.) I can't afford -- emotionally or pragmatically -- to be any dumber than I already am.  Living life with chronic pain like I've had the past several weeks is not an option.

My orthopedic doctor is having me do a shoulder aspiration on Monday.  This is where they draw some fluid from the shoulder area and send it for a battery of tests to check for any signs of infection.  It's also a requirement for surgery.  (Because you really, really, don't want a bone infection.)  So, unless there's significant improvement in the shoulder and attendant pain in the next few weeks (it takes about two weeks to get full test results back), I most likely will be having a new round of shoulder surgery sometime after that.

(Scheduling will partly depend on how much objection Workmens' Comp raises to the idea of a complete re-do of surgery.  I've actually been astonished by how cooperative and quick Travellers Insurance --who provide Workmens Comp insurance coverage for my employer -- has been in covering all the expenses.  On the other hand, they've already laid out over $100,000 on my case, and might want to send me for, at the least, a second opinion before agreeing to a new operation.)

I'm not at all happy about the idea of a second surgery, one that will put my progress back to the point immediately after the last surgery, with still more months of recovery and therapy following.  This seems an appropriate visual reference: